I enjoyed the May case report, “Lateral open bite: treatment and stability” (Cabrera MC, Cabrera CAG, de Freitas KMS, Janson G, de Freitas RM. Am J Orthod Dentofacial Orthop 2010;137:701-11) and would like to congratulate the authors on achieving an ideal occlusion, specifically moving the maxillary left canine and the first and second premolars buccally out of crossbite.

The gingival recession on these teeth as well as on the mandibular left central incisor two years post-treatment merits some discussion, as periodontal health is sometimes overlooked at the treatment planning appointment. I argue for prophylactic soft-tissue grafting in the mandibular anterior and maxillary right posterior sextants before orthodontic movement out of the alveolar housing.

The patient had several risk factors for recession. First, he presented with a thin, scalloped periodontal biotype. Second, although there is no clear consensus on what constitutes “thin” gingiva, one method is visualization of the shadow of the periodontal probe through the sulcus. In this case, we assume that it is thin because the outline of the roots can be seen through the gingiva. Thin tissue is more likely to recede due to trauma or orthodontic movement than normal or thick tissue. In fact, the patient presented with initial signs of recession (maxillary left central incisor).

Classic orthodontic-periodontic literature has consistently shown that bone and gingival recession occur as the dentition moves outside of the alveolar housing. According to Miller’s classification any bone or papilla recession interproximally reduces the predictability of complete root coverage. Therefore, soft tissue grafting in cases similar to this is more predictable before orthodontic treatment is initiated.